Behavior Think Sheet. I used something similar to this with some of my students who needed time away from the situation to settle down before discussing the problem with me.
Tween Teaching: Behavior Reflections Sheet
How I Create and Maintain A Positive Classroom Culture for K-2!
Owl Clip Chart for Classroom Management and a Behavior Think Sheet Freebie
Task 1: how we can manage behavior by having them think about what they have done wrong
Behavior Think Sheet
Behavior Reflection Sheet
TPT Freebie! Think Time Slip for students to evaluate their behavior. There is even a place for a parent signature.
Behavior Reflection Sheet Single page
Upper Elementary Snapshots: Successful Parent Teacher Conferences